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ISSN: 2320-5407 Int. J. Adv. Res.

5(11), 120-131

Journal Homepage: -www.journalijar.com

Article DOI:10.21474/IJAR01/5745
DOI URL: http://dx.doi.org/10.21474/IJAR01/5745

RESEARCH ARTICLE

MINI - RETROMANDIBULAR APPROACH FOR OPEN REDUCTION AND INTERNAL FIXATION OF


CONDYLAR FRACTURES BY DELTA PLATES: AN EXPLORATORY STUDY.

Dr. Sujeeth Kumar Shetty, Mds, Dr. Vijay Singh Rai, Mds, Dr. Sai Krishna D., Mds, Dr. Asutosh Das, Mds
and Dr. Praveen Kumar Singh, Mds.
....
Manuscript Info Abstract
.
Manuscript History Background: The main objective of our study is to evaluate the new
delta condylar plate for condylar fracture with mini retromandibular
Received: 02 September 2017 approach.
Final Accepted: 04 October 2017 Materials and methods: 20 patients with displaced condylar fracture
Published: November 2017
were treated with delta condylar plate using mini retromandibular
Key words:- approach. Patients were evaluated on the basis of pre op and post op
Mini retromandibular approach.Delta parameters and X-rays. Patients were followed for 18 months.
condylar plates.Condylar fracture. Results: In 20 patients, there was high male predominance (75%) to
female (25%). The mean mouth opening is 44.85mm (40-50mm). The
duration of surgery varied from minimum of 40 min to maximum of 65
min (mean= 52.95 min ). In this study excellent access was achieved in
14 cases (70%), access was good in 5 cases (25%) & fair in 1 case
(5%). Post operative complications like infection at surgical site (25%)
is in 5 cases &sialocele (15%) in 3 case. We didnt encounter any facial
nerve palsy. All 20 patients (100%) had inconspicuous scar which was
well camouflaged.
Conclusion: The mini retromandibular approach is easy and fast to
perform and carries low risk of damaging the facial nerve while leaving
a barely noticeable scar . Delta shaped plate for condylar fractures aids
in neutralization of changing strains and the plate can be easily place at
the constricted condylar neck region. We concluded that surgical
treatment of the fractured, displaced condyle using the mini
retromandibular approach for anatomic reduction using delta condylar
plates is excellent.

Copy Right, IJAR, 2017,. All rights reserved.


....
Introduction:-
Trauma is a major health and social issue in the World. Every year people of all ages sustain facial injuries from
automobile and other vehicular collisions, firearms, athletic activities, or altercations. Many of these injuries have
maxillofacial fractures such as fractures of the lower jaw, upper jaw, palate, cheekbones, nose, bone surrounding the
eyes, skull, injuries to the teeth or combination injuries.[1]

With an incidence rate of 36% to 70%, mandibular fracture is the most common fracture of the maxillofacial
complex.[2] The temporomandibular region is certainly not exempt from injury. Among mandibular fractures,

Corresponding Author:- Sujeeth Kumar Shetty. 120


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mandibular condylar fractures represents 26% to 57% of all mandibular fractures[3]. The complexity of this region
and its anatomic proximity to other craniofacial structures make diagnosis and treatment especially challenging.[4]

For decades, moderately displaced condylar fracture have been treated with closed reduction consisting of inter
maxillary fixation followed by physiotherapy. Conservative treatment is easier and less invasive with no surgical
complications. Consequently, several publications have emphasized the acceptable functional results of conservative
treatment in contrast to the risks of surgery.[5]

Long-term follow up studies on condylar fractures treated conservatively have shown that growth disturbances or
dysfunction of the masticatory system in young people. In meta analysis study conducted by Essam Ahmed and
Edward Ellis in 2014, they confirmed that open and internal fixation of condylar fractures have superior functional
clinical outcome subjectively and objectively in comparison to conservative management.

Among the various approaches for open reduction and internal fixation of the condylar fracture, retromandibular
approach is easier and safer than submandibular approach & the access is much more superior when compared to the
preauricularapproach[6].The only disadvantage is a noticeable scar. To eliminate the scar we used mini
retromandibular approach which is 20 mm in length in comparison to 30-40 mm in retromandibular incision.
Incision is given posterior to the ramus of mandible and 1cm caudal to the radix of the auricular lobule.[7]

Different kinds of fixation methods have been used for condylar fractures such as wires, pins, screws, and plates.
Fixation with rigidminiplates provides more stability than transosseous wiring. The miniplate system available
today facilitates fragment fixation, although bone resorption in connection with miniplates has been reported[8].

Single miniplate fixation is adequate if the fragments are aligned properly. If functional forces actually exceed the
rigidity of one miniplate, then the use of two has been proposed. Alternatively, a single 2.4 mm plate or a single 2.0
mm mini-dynamic compression plate may be used for fixation of condylar fractures, as they offer more resistance to
rotation and 3-point bending. However, in the condylar fractures, the amount of bone is not always adequate to
permit placement of 23 screws per fragment.

To overcome this problem, various plate designs have been put forward such as L shape, Y shape, or 3-D plate for
condylar fractures, which helps in neutralization of the stress patterns at the condylar region[9]. Delta condylar plate
is a 3-D plate, shaped for adaptation in the anatomically constricted region of condylar region. The Delta plate is
triangular shape with thickness of 1 mm and a length of 20 mm. The plate is 5 mm broad at the top and 12 mm at
the bottom. The two horizontally placed holes are present at the base of the plate.(Figure 1). Due to its small
triangular shape design, the plate can be more easily be placed on the condylar process than the double-plate and at
the same time ensures a stable and functional osteosynthesis[10].

So in the study we have evaluated the use of delta plate for condylar fracture with mini retromandibular approach.

Material and Methods:-


Twenty patients who have U/L or B/L condylar fractures with associated mid face fractures were randomly selected
for open reduction and internal fixation from Department of Oral and Maxillofacial Surgery, J. S. S. Dental College
& Hospital, Mysore, Dental Out Patient Department, J. S. S. Medical College & Hospital, Mysore from 2015 -
2016.

Inclusion Criteria:-
1. Adult patients of age 18 - 55 years both sexes
2. Bilateral or unilateral condylar fractures with associated mid face fractures
3. Condylar fractures with occlusal derangement
4. Condylar fractures with functional interference
5. Patients who cannot tolerate IMF for long duration

Exclusion Criteria:-
1. Patients who have undergone previous surgery or trauma in the proposed surgical site.
2. Patients who have familial tendency to form hypertrophic scar.
3. Patients with structural deficits of condyle.

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4. Patients with history of pathology in pericondylar region.


5. Patients with systemic bone diseases.

All the subjects received intravenous antibiotics from the time of admission until discharge. Following this, 5-day
course of oral antibiotics is prescribed. We follow a regular protocol which includes pre-surgical evaluation of the
patient, diagnosis of the fracture (OPG,PA view mandible)(Figure 2) routine blood investigations and treatment
plan. Following initial preparation procedure, clinical parameters and radiographic findings were recorded followed
by open reduction and internal fixation using Delta Titanium condylar plates via mini retromandibular approach
under general anaesthesia. Relevant clinical parameters were assessed preoperatively, intraoperatively &
postoperatively, followed by weekly follow up for six weeks.

Surgical Technique:-
After skin preparation & draping the site, local infiltration of 2% xylocaine with adrenaline was given after marking
the incision line. Incision of length 2 cm is made in a natural crease of the neck beginning from 1 cm under the
mastoid apex and running parallel to the anterior aspect of the sternocleidomastoid muscle. After dissecting through
the skin, subcutaneous fat and platysma, the SMAS and underlying parotid fascia were identified and incised
parallel and 5.0 mm anterior to the posterior rim of the ramus. Blunt dissection through the parotid gland done with
a hemostat parallel to the anticipated direction of the facial nerve. The tough parotid septa was then divided. When
branches of the facial nerve were encountered, usually at least 5.0 mm deep to the parotid fascia, they were retracted
anteriorly. Masseter muscle was exposed, dissection carried out posteriorly , pterygomasseteric sling incised.
Subsequently, a subperiosteal dissection was carried out till the sigmoid notch and the fracture site exposed.
Fracture was then reduced by applying traction on the mandibular angle and pulling it down. When reduction was
achieved, the condyle was fixed with using Delta titanium condylar plate and four monocorticalscrews (Figure 6).
Occlusion and joint mobility was checked. The surgical field was then irrigated & inspected, followed by meticulous
hemostasis. The pterygomasseteric sling was reconstructed using 3-0 vicryl sutures. Branches of facial nerve
carefully inspected. The parotid fascia and SMAS were repaired to attain a watertight closure using 3-0 vicryl to
prevent salivary fistula. Subcutaneous sutures were placed using 4-0 vicryl/polygalactine. The skin was closed with
interrupted sutures using 4-0 or 5-polypropylene suture. Pressure dressing was given which was left in place for 48
hours.

Patients were evaluated clinically and radiologically for the following parameters:
1. Surgical access graded excellent, good & fair
2. Duration of surgery
3. Anatomic reduction assessment with relevant radiographs
Evaluation was done by comparing the pre & post operative radiographs and was graded as
Anatomically correct: Correct open reduction
Good: Shortening less than 2.0 mm
Satisfactory: Shortening less than 5.0 mm
Poor: Values above those mentioned
4. Occlusal discrepancies: The changes in occlusion were noted. This was assessed clinically by inspecting
abraded surfaces of the teeth, as well as subjectively by the patients.
5. Need for post operative IMF
6. Facial nerve morbidity: Facial nerve injury was deemed to have occurred if the patient was unable to draw the
lower lip and corner of the mouth downward, was unable to whistle, or was unable to completely close the
eyelids or wrinkle the brow.
7. Sialocele, salivary fistula etc
8. Hematoma
9. Mouth opening: Inter incisal clearance was measured with a willis gauge
10. Auricular anaesthesia: To evaluate post operative function of the greater auricular nerve, the sensory reaction
of the external ear was investigated by means of a pinprick test.
11. TMJ symptoms like joint pain, deviation of the mandible on opening etc.

Deviation of the mandible was assessed by the surgeon clinically. Pain was perceived by the patient. Severity of the
pain was assessed using a visual analogue scale which was given to patients as printed proforma during follow up
days:

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Visual analogue scale: score (0 10)


No pain Pain cannot be worse.
0 1 2 3 4 5 6 7 8 9 10
12. Plate Infection, plate fracture etc
13. Scar: Patients were reviewed at regular intervals and the character of the scar was assessed by both the patient &
the surgeon clinically. The character of the scar was graded as: inconspicous, conspicous, hypertrophic.

The data collected were subjected to statistical methods comprising of Descriptive statistics, Cross Tabs, and Paired-
samples t test & Chi-Square Test. SPSS (Statistical presentation system software) for windows Version-16 was
employed for statistical analysis.

Results:-
Age distribution:-
In the study they were totally 20 pts in number , we noted 9 cases(45%)in the age group of 18 - 25 yrs, 9(45%)
cases in age group of 26-35 yrs and noted 2 cases (10%) in the age group of 36-55 yrs. Mean age being 28.7 in male
and 33.8 in female. Cramer's V value for the age and sex distribution found to be 0.310 which is 0.382 significant .

Sex distribution:
In 20 patients, they were 15 (75%) male pts and 5 (25%) female pt.

Mechanism of injury:
5 (25%) pts sustained the injury due to road traffic accidents. 15(75%) cases sustained injury due to self fall. Chi
square value found to be 5.000 at a P value of 0.025.

Type of condylar fracture:


11 cases (55%) sustained Type II fracture and 9 cases (45%) sustained Type III fracture. Chi square value found to
be 0.200 at a P value of 0.655.

Associated fractures:
There was 1(5%) case isolated condylar fracture, parasymphysis fracture was noted in 8 cases (40%) &symphysis
fracture in 7 cases (35%), body fracture in 4 cases (20%). Chi square value found to be 5.000 at a P value of 0.025.

Side of the fracture:


In 20 pts, 9 cases (45%) sustained unilateral fracture of condyle & 11 cases (55%) sustained bilateral fracture of
condyle.Chi square value found to be 4.900 at a P value of 0.086.

Duration of surgery:
Duration of surgery was found to be min of 40 min - 65 min with a mean of 52.95 min.

Surgical access:
Access was rated as excellent, good & fair. In this study excellent access was achieved in 14 cases (70%), access
was good in 5 cases (25%) & fair in 1 case (5%). Chi square value found to be 13.300 at a P value 0.001.

Plating:
In 11 bilateral condylar fracture, only 1 patient(9.9%) was plated on both sides with the delta condylar plate.

Anatomic reduction:
Anatomic reduction was rated as anatomically correct, good & satisfactory with the help of postoperative
radiographs. In this study anatomically correct reduction was achieved in 10 cases (50%). Good reduction was
achieved in 8 cases (40%) and satisfactory in 2 (10%) cases. Chi square value found to be 5.200 at a P value .074.

Post operative occlusion:


Postoperative occlusion was rated as deranged or normal. A normal occlusion was achieved in 17(85%) cases
,occlusion was found to be deranged in 3 cases (15%). Cramer's V value for post operative occlusion is 0.860 at
P=0.00, which is statistically significant.

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Need for intermaxillary fixation postoperatively:


There was no need for post operative IMF in 3 cases (15%) Postoperative IMF was required in 17 cases (85%).
Cramer's V value found to be 0.285 at a P value 0.072.

Post operative mouth opening:


The mean mouth opening pre op was 21.05 and post op was 44.85. The paired sample test was found to be -
23.80000 at P=0.000, which is statistically significant.

Complications encountered:
We encountered two types of complications postoperatively namely wound infection in 5 cases (25%) and sialocele
in 3 cases (15%). Chi square value found to be 22.000 at a P value 0.000, which is statistically significant.

TMJ Dysfunction:
We encountered two types of TMJ dysfunction in this study i.e., ipsilateral deviation on opening the mouth and pain
on opening the mouth which was assessed subjectively by the patient & was given a VAS score ranging from 1-10
depending on the severity. In this study, ipsilateral deviation of the mandible was noted in 2 case (10%). Mild pain
with a vas score of 2 was reported in 2 cases (10%), score 3 and 2 in 1 patient (9.1%). Chi square value found to be
15.700 at a P value 0.000, which is statistically significant.

Post Operative Scar:


Scar was assessed clinically & was graded as conspicuous, inconspicuous or hypertrophic. In this study after a
period of six months all 20 patients (100%) had an inconspicuous scar which was well camouflaged (Figure 5).
Cramer's V value found to be 1.000 at a P value 0.000, which is statistically significant.

Discussion:-
Mandibular fractures are frequent in facial trauma and about 30 % involve the condyle.(De Riu et al, 2001.) The best
treatment strategy, that is, closed or open reduction and internal fixation, remains controversial (Santler et al, 1999).
Closed treatment has been the preferred treatment for several years, however longterm complications include open
bite, pain, inadequate restoration of vertical height of the ramus, arthritis, and deviation of the mandible (Singh et al,
2012).

The open reduction and rigid internal fixation allows for good anatomic repositioning, restoration of the ramal
length, avoidance of long term sequel like clicking and late arthritic changes and an earlier return to normal function
without the need for inter maxillary fixation. Because of this early return to function, the chances for ankylosis is
greatly reduced. Due to all these reasons and advantages there is an increase in the interest among majority of the
surgeons to manage condylar fracture by ORIF[11].

In 1925 Silverman described the first method of ORIF of the condyle by an intraoral route, principally for low
subcondylar fractures. Since then several techniques have evolved. Koberg and Momma described the
retromandibular approach for plate and screw fixation whereas Petze and then Eckelt in the early 1980s described
methods of fixation with lag screws by a submandibular approach. Kitayama described a method for the intraoral
placement of a lag screw[12].

Multiple approaches have been proposed and used in order to visualize and reduce condylar fractures which include
the intra oral, coronal, preauricular, face-lift (Rhytidectomy), post auricular, endural, endoscopic, retromandibular,
and submandibular and often in combination. Potential damage to facial nerve and its branches with some
approaches and possibility of post operative scar have drastically affected the choice of surgical approach.
Retromandibular approach deserves special attention as it is ideally suited to the technique of miniplate
osteosynthesis in the area of difficult access. This approach seems to give the benefits of the good cosmetic and a
adequate exposure for manipulation and reduction of the fracture and for placement of fixation.

The mini retromandibular approach is a conservative modification of the retromandibular approach mentioned in
literature, in that the incision proposed is only 2 cm long as opposed to the classical incision of 2.5-3cm[13]. The
advantages of the approach is the subcutaneous dissection allows the extension of the surgical wound to the level of
the fracture. In all phases, the surgery performed is perpendicular to the fracture which facilitate the reduction of
medially displace proximal stumps which are generally very hard to manage in other approaches. The articular

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capsule is never breached which is a major post operative function advantage[14].In our study of 20 patients, there
was high male predominance (75%) to female (25%), with a P value of 0.007 which is significant ,which can be
correlated to the study of Marker et al(2000) out of 348 pts, 230 were men and118 were women[3].

The high percentage of the patients were found in age group of 26-35(45%), mean age is 28.7 in male and 33.8 in
female, which is similar to the study of Marker et al(2000). It can be seen that in men there is a concentration of
fractures in the second and third decades[3].

Road traffic accidents and self fall accounted for the majority of patients. This finding is in agreement with the
studies done by several authors . In our study, out of 20 pts 5 cases of RTA (25%) , 15 cases of self fall (75%) were
noted. In a study conducted by Newman et al(1998) the most common cause of condylar fracture was cited as
RTA(33%),and fall(52%)[12].In a study conducted by Pereira Max et al (1995)which stated that the majority of
fractures were the result of car accidents (five cases), fall from a bicycle (five cases),falling down (three) and
physical aggression (two).[15]

In our study out of 20, 9(45%) cases were unilateral fractures of the condyle & 11(55%) cases were bilateral
fractures. In the series of studies conducted by Marker et al (2000)[3] . He reported that of the total sample size of
444,252 of unilateral and 192 bilateral[3] &out of 45, 30(67%) had a unilateral fracture of mandibular condyle &
15(33)% sustained bilateral fracture of the condyle[16].

When considering the associated injuries fracture of parasymphysis(40%)and fracture of the symphysis(35%) and
fracture of body 4(20%) was the most common associated fractures. Isolated condylar fracture is seen in 1(5%)
patient. In a study conducted by Hyde et al(2002), showed that it was associated invariably with parasymphysis[20]
and study conducted by Marker et al(2000), showed that fracture of the symphysis was the most common(79%)[3].

The type of fractures were classified according to Spissel&Schroll (1972)[17] . Out of 20 patients, 11 patients
sustained Type II fracture (55%), 9 cases were classified as Type III (45%)which was similar to the study conducted
by Schneider et al(2007), where out of 45 condylar fractures, 36 fractures were type II, 3 patients sustained type III
fracture & 7 cases were type IV fractures.[18]

The duration of surgery varied from minimum of 40 min to maximum of 65 min (mean= 52.95 min ). This is more
in relation to operative time taken by Federico Biglioli et al(2008)[19], according to which mean operating is 32
min/condyle. Time taken to complete the dissection also was dependent on the amount of fracture displacement and
the type of patient. In our study the additional time was required for the placement of the Delta titanium condylar
plate.

Access was rated as excellent, good and fair. In this study excellent access was achieved in 14 cases (70%), access
was good in 5 cases (25%) & fair in 1 cases (5%), this is consistent with study conducted by S. Shah et al which
states that this approach provides adequate exposure and reduction, minimum nerve injury and minimum
scarring[16].

The anatomic reduction was graded as Anatomically correct, Good, Satisfactory and Poor according to Hochban et
al(1996)[21] and in our study 10 (50%) cases were anatomically correct, 8(40%) cases were Good, 2(10%) cases
were satisfactory(Figure 3).

In a study conducted by MaciejSikora et al, (2016) which showed that the delta titanium condylar plate were able to
provide stable osteosynthesis to condylar fractures with practically no risk of breaking of the plate and failure in
form of the loosening of the retaining screws and does not causes any significant disturbances in the fracture healing
process. The primary stability achieved by delta titanium condylar plate was superior to that obtained by single
plating techniques.

A prospective study conducted by Kumaran S et al, for analysis of two different surgical approaches preauricular
and mini retromandibular approach for mandibular condylar fractures. He summarizes the mini retromandibular
approach is extremely easy and fast to perform and carries low risk of damaging the facial nerve whilst leaving a
barely noticeable scar.

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When considering the occlusal discrepancies, the occlusion was deranged in all the 20 cases preoperatively which
was also an indication of ORIF. Postoperatively occlusion was achieved in 17 cases (85%). Occlusion was found to
be derranged in 3 cases (15%).

In a study conducted by Marker et al (2000), it was observed that the occlusal disharmony was associated other
fractures of mandible involved[3].However in our study all the cases with post operativeocclusal derangement was
managed with post operative IMF with elastics for a period of one to two weeks which corrected the problem. There
was no need for post operative IMF in 3 cases (15%) Postoperative IMF was required in 17 cases (85%).

A study conducted by Widmark et al (1996) showed that postoperatively, in one third all male patients (six unilateral
fractures and one bilateral fracture), IMF was used. A tendency to occlusal disturbance was seen in these patients at
the end of the operation, after plating the fracture, as it was doubtful whether they could cooperate and follow the
postoperative instructions for a soft-food diet and avoidance of violent physical contact with others[8]. Several
authors,[3][8][22] have combined miniplateosteosynthesis with intermaxillary fixation. Zide.F.M et al
(1983)[23]used IMF for 6 weeks after fixation of condylar fracture with wires using the rhytidectomy approach.

The mean post operative mouth opening is 44.85mm (40-50mm) with a P value of 0.000 which is statically
significant. Similar studies done by various authors on mouth opening were observed as Zide and Kent et
al(1983)[23]:45 mm, Perira et al (1995:35-50mm (41.9mm)[15], Widmark et al (1996)[8]:40-67mm (51mm), Schon
et al(2002)[24]:40mm.

We encountered some postoperative complications like infection at surgical site (25%) in 5 cases &sialocele (15%)
in 3 case, with a P value of 0.000 which is statistically significant. We didnt encounter any facial nerve palsy as the
dissection was done through masseter reflecting parotid anteriorly this in consistent with the study done by Wilson
et al (2005)[14] which showed that the area next to the anterior edge of the parotid gland is usually relatively free of
branches of the facial nerve, making this an ideal point to dissect down to the fracture if a buccal branch crosses the
field it is easily retracted up or down.

The infection resolved during the course of 10 day per oral antibiotics and sialocele got resolved spontaneously in a
period of 3-5weeks which the pressure dressings. We encountered two types of TMJ dysfunction in this study i.e,
ipsilateral deviation on opening the mouth and pain on opening the mouth which was assessed subjectively by the
patient using and was given a VAS score ranging from 1-10 depending on the severity.

There were two cases of pain which were scored as VAS- 2(10%) & VAS-3(5%) and 2 case of ipsilateral deviation
(10%) on opening mouth, with a P value of 0.000 which is statistically significant. Ipsilateral deviation progressively
decreased and disappeared in 2-3 months period, patients were advised mirror exercises.

Patients who complained of pain were treated symptomatically &was resolved completely in a period of 1-2 months.
Practically the problems of pain and hypomobility may complicate both open and closed reduction. The
physiotherapy was goal oriented until an opening mouth with full range of excrusion and will prevent some late
complications like ankylosis and post traumatic functional abnormalities Yasuharu et al(1990)[22].

In study conducted by Widmark et al(1996) which showed 2mm deviation to the operated side on mouth
opening[8]. In study conducted by Hyde et al(2002) out of 25 pts 12 pts had mandibular deviation on opening mouth
was noted[20]. In as study done by Vesnaver et al(2005) 7(21%) pts had deflection had deflection, 4(12%) to the
same side and 3 (9%) to the contralateral side[25].

Scar was assessed clinically & was graded as conspicuous, inconspicuous or hypertrophic. In this study after a
period of 6 months, all 20 patients (100%) had inconspicuous scar which was well camouflaged.

The principles behind open reduction and internal fixation with miniplateosteosynthesis is functionally stable
osteosynthesis as proposed by Champy et al (1975) and Champy and Lodde (1976). Champy determined the ideal
line of in the region of mandibular body but no such lines was proposed in the region of condyle because of limited
data. Meyer et al (2002) attempted to fill this void to determine the ideal line of osteosynthesis in the region of
condyle. During biting forces in the region of molars, strain lines were detected in the condylar region. 4 hole

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miniplate parallel to the condylar axis was found to provide compression osteosynthesis and similar plates in the
region parallel to mandibular notch provide dynamic osteosynthesis.

Hence, adaption of single 4 hole miniplate, as was initially proposed did not provide dynamic osteosynthesis and
resulted in fracture of the plating during function.. 2 plate fixation (1 miniplate parallel to condylar axis and second
miniplate parallel to mandibular notch ) met with the fulfilment of dynamic osteosynthesis. Single plate parallel to
condylar axis if used as fracture reduction and second plate parallel to mandibular notch provides dynamic
osteosynthesis. But adaptation of two miniplates in the region of condylar axis is difficult due to constriction of
condylar neck.

In our study, the delta condylar plate stabilize the condylar fracture as one side is parallel to the sigmoid notch and
other side comes parallel to the posterior border which results in good anatomic reduction of fracture with minimal
complications. The only disadvantage of being slight difficulty in fixing of the plate. Due to its shape,
neutralization of changing strains at the anterior, lateral, and posterior borders in condylar neck region is noticed
which lead to stability of the fractured fragment[26].

Among the approaches to condyle, miniretromandibular approach is easy and fast to perform, presents a very low
risk of the facial nerve and leaves a barely noticeable scar in a relatively hidden region. The other advantages is of
shorter working distance from the skin incisions to the condyle which provides greater access to the posterior border
of the mandible and the sigmoid notch.

Conclusion:-
Facial injuries are most commonly associated with falls, motor vehicle accidents, sports-related trauma, and
interpersonal violence. The temporomandibular region is certainly not exempt from injury related to these factors.
The treatment of injuries to the temporomandibular joint (TMJ) and its surrounding region is one of the more
controversial areas in management of facial trauma.

A variety of fixation methods are available like plating, lag screw fixation, transosseus wiring, pin fixation
techniques and external fixators. Bone plating through a preauricular, submandibular, or retromandibular approaches
are the most commonly employed techniques.

Mini Retromandibular approach is easier and faster to perform and carries low risk of damaging the facial nerve
whilst leaving a barely noticeable scar. In considering the anatomic reduction of the fracture, posterior border of the
mandible can be visualized throughout the surgery.

Using the Delta condylar plate for condylar fractures has 3 main advantages: 1) neutralization of changing strains at
the anterior, lateral, and posterior borders; 2) the additional stabilization provided by a compression miniplate; and
3) a small, manageable osteosyntesis plate. The new design of Delta Trilocking plate has the gliding holes which
help to compress the fracture through screw adjustments, which accelerate bone healing.

On the basis of these clinical results as well as the degree of patient satisfaction, it may be concluded that surgical
treatment of the fractured, displaced or undisplaced condyle using the Mini retromandibular approach with anatomic
reduction using Delta condylar plates are excellent.

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Figure 1:-Delta condylar plate

Figure 2:-Pre operative OPG X-ray.

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Figure 3:-Post operative OPG X-ray

Figure 4:-Pre operative profile view

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Figure 5:-Post operative profile view after 6 months

Figure 6:-Intra operative Delta plate

References:-
1. Parameters of Care: Clinical Practice Guidelines for Oral and Maxillofacial Surgery (AAOMS ParCare 2012) J
Oral MaxillofacSurg ;70:e162-e203
2. Dr. Narendra N. Hirani, Dr. NishantPujara. Comparison of Open Reduction and Internal Fixation in Case of
Symphysis and Parasymphysis Mandible Fracture . International Journal of Science and Research (IJSR), June
2015; Volume 4 Issue 6
3. P.Marker, A.Nielson,H.Lehmann Bastian. Fractures of the mandibular condyle.Part 1:Patterns of distribution of
types and causes of fractures in 348 patients. British journal of Oral & Maxillofacial surgery, 2000;38:417-421.

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4. Fonseca R.J, and Robert V. Walter. Oral and maxillofacial trauma Pennsylvania; W.B.Saunders company;
2005;3(1):524.
5. UweEckelt,MatthiasSchneider,Francois Erasmus et al. Open versus closed treatment of fractures of the
mandibular condylar process-A prospective randomized multi-centre study, Journal of cranio-maxillofacial
surgery 2006;34:306-314.
6. Chossegros.C, Cheynet.F, Blanc.J, Bourezak.Z. Short retromandibular approach of subcondylar fractures. Oral
Surg Oral Med Oral Pathol Oral RadiolEndod. 1996;82:248-52.
7. Maria Cecilia Closs Ono, GilvaniAzor de Oliveirae Cruz, Renato da Silva Freitas. Mini
retromandibulartransparotid approach for extracapsular condylar fractures of the mandible. Brazilian Journal of
Plastic Surgery. 2013;28(3):428-33.
8. G.Widmark, T.Bagenholm, K.E.Kahnberg,et al. Open reduction of subcondylar fractures.A study of functional
rehabilitation. Int. J. Oral MaxillofacSurg; 1996;25:107-111.
9. ManojChaudhary, Harshvardhan pant, Manpreet Singh, ArpitVashistha, Gagandeepkaur. Evaluation of
trapezoidal-shaped 3-D plates for internal fixation of mandibular subcondylar fractures in adults. Journal of
Oral Biology and Craniofacial Research 5 (2015), I34-I39.
10. MaciejSikora, MarcinSielski, AgataStapor, DariuszChlubek, Use of the Delta plate for surgical treatment of
patients with condylar fractures. Journal of Cranio-Maxillo-Facial Surgery 43(2015)1961-1965.
11. A.P. Mohan et al. Comparison of preauricular approach versus retromandibular approach in management of
condylar fractures. J Maxillofacial oral surg 2012;11(4):435-441.
12. Newman.L. A clinical evaluation of the long-term outcome of patients treated for bilateral fracture of the
mandibular condyles, British journal of oral and maxillofacial surgery 1998;36:176-179.
13. Kumaran S, Thambiah LJ. Analysis of two different surgical approaches for fractures of the mandibular
condyle. Indian Journal of Dental Research, 23(4), 2012;23:463-468
14. Wilson.A.W, Ethunandan.M, Brennan.P.A. Transmassetericantero-parotid approach for open reduction and
internal fixation of condylar fractures. British journal of oral and maxillofacial surgery 2005;43:57-60.
15. Pereira M. D Marques , A, Ishizuka M ,. Keira S M , Brenda E , Wolosker A B. Surgical treatment of the
fractured and dislocated condylar process of the mandible. . Journal of Cranio-Maxillofacial Surgery
1995;23:369-376.
16. S. Shah,S. Ali,AMirza: RetroparotidTransmasseteric Approach to condylar fracture through Mini-
retromandibular access;AAOMS;2011;session 4;e-37
17. Gunter Lauer, Winnie Pradel, Matthias Schneider, UweEckelt, A new 3-Dimensional plate for transoral
endoscopic-assisted osteosynthesis of condylar neck fractures. Journal of Oral Maxillofacial Surgery (2007)
65:964-971
18. Schneider.M,Lauer.G,Ecklet.U. Surgical treatment of fractures of the mandibular condyle: A comparison of
long term results following different approaches Functional, axiographical, and radiological findings. Journal
of Cranio-Maxillofacial Surgery 2007; 35:151-160.
19. Federico Biglioli, GiacomoColletti. Mini - retromandibular approach to condylar fractures. Journal of Cranio-
Maxillofacial Surgery (2008) 36, 378-383
20. Hyde.M, Manisali.M, Aghabeigi.B, Sneddon.K, Newman.L. The role of open reduction and internal fixation in
unilateral fractures of the mandibular condyle: A prospective study. British Journal of Oral and Maxillofacial
Surgery 2002; 40:19-22.
21. Devlin M. F, Hislop W. S, Carton A. T. M. Open reduction and internal fixation of fractured mandibular
condyles by a retromandibular approach: surgical morbidity and informed consent. British journal of oral and
maxillofacial surgery.2002;40:23-25.
22. Takenoshita.Y, Ishibashi.H, Oka.M, Comparison of functional recovery after non-surgical & surgical treatment
of unilateral dislocated low subcondylar fractures. J Oral Maxillofac Surg.1990; 48:1191-1195.
23. Zide.M.F, Kent.J.N.Indications for open reduction of mandibular condyle fractures, J.Oral&MaxillofacSurg
1983;41:89-98.
24. Schon.R, Gutwald.R.,Schramm.A, Gellrich.N.C, Schmelzeisen. R. Endoscopy assisted open treatment of
condylar fractures of the mandible:extra oral vs intraoral approach. . J. Oral Maxillofac Surg. 2002;31:237-243.
25. Vesnaver.A, Gorjanc.A, Eberlinc.A, .Dovsak. Akansky.A.A. The periauriculartransparotid approach for open
reduction and internal fixation of condylar fractures. Journal of cranio-maxillofacial surgery, 2005:33,169-179.
26. ShaileshNareshkumarKokal, SurajArjunAhuja, Nareshkumar T Kokal, Haemant A Baonerkar. Clinical
experience with osteosynthesis of subcondylar fractures of the mandible using Delta plate. Journal of
Contemporary Dentistry, January-April (2016);6(1):63-66

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